Michele Saysana

Summary of STARNet: Seamless Transitions and (Re)admissions Network

The Seamless Transitions and (Re)admissions Network (STARNet) met in December 2012 to synthesize ongoing hospital-to-home transition work, discuss goals, and develop a plan to centralize transition information in the future. STARNet participants consisted of experts in the field of pediatric hospital medicine quality improvement and research, and included physicians and key stakeholders from hospital groups, private payers, as well as representatives from current transition collaboratives. In this report, we (1) review the current knowledge regarding hospital-to-home transitions; (2) outline the challenges of measuring and reducing readmissions; and (3) highlight research gaps and list potential measures for transition quality. STARNet met with the support of the American Academy of Pediatrics’ Quality Improvement Innovation Networks and the Section on Hospital Medicine.

Reduction in Pediatric Identification Band Errors: A Quality Collaborative

BACKGROUND AND OBJECTIVE: Accurate and consistent placement of a patient identification (ID) band is used in health care to reduce errors associated with patient misidentification. Multiple safety organizations have devoted time and energy to improving patient ID, but no multicenter improvement collaboratives have shown scalability of previously successful interventions. We hoped to reduce by half the pediatric patient ID band error rate, defined as absent, illegible, or inaccurate ID band, across a quality improvement learning collaborative of hospitals in 1 year. METHODS: On the basis of a previously successful single-site intervention, we conducted a self-selected 6-site collaborative to reduce ID band errors in heterogeneous pediatric hospital settings. The collaborative had 3 phases: preparatory work and employee survey of current practice and barriers, data collection (ID band failure rate), and intervention driven by data and collaborative learning to accelerate change. RESULTS: The collaborative audited 11 377 patients for ID band errors between September 2009 and September 2010. The ID band failure rate decreased from 17% to 4.1% (77% relative reduction). Interventions including education of frontline staff regarding correct ID bands as a safety strategy; a change to softer ID bands, including “luggage tag” type ID bands for some patients; and partnering with families and patients through education were applied at all institutions. CONCLUSIONS: Over 13 months, a collaborative of pediatric institutions significantly reduced the ID band failure rate. This quality improvement learning collaborative demonstrates that safety improvements tested in a single institution can be disseminated to improve quality of care across large populations of children.

A Quality Improvement Collaborative to Improve the Discharge Process for Hospitalized Children.

OBJECTIVE: To assess the impact of a quality improvement collaborative on quality and efficiency of pediatric discharges. METHODS: This was a multicenter quality improvement collaborative including 11 tertiary-care freestanding children’s hospitals in the United States, conducted between November 1, 2011 and October 31, 2012. Sites selected interventions from a change package developed by an expert panel. Multiple plan–do–study–act cycles were conducted on patient populations selected by each site. Data on discharge-related care failures, family readiness for discharge, and 72-hour and 30-day readmissions were reported monthly by each site. Surveys of each site were also conducted to evaluate the use of various change strategies. RESULTS: Most sites addressed discharge planning, quality of discharge instructions, and providing postdischarge support by phone. There was a significant decrease in discharge-related care failures, from 34% in the first project quarter to 21% at the end of the collaborative (P < .05). There was also a significant improvement in family perception of readiness for discharge, from 85% of families reporting the highest rating to 91% (P < .05). There was no improvement in unplanned 72-hour (0.7% vs 1.1%, P = .29) and slight worsening of the 30-day readmission rate (4.5% vs 6.3%, P = .05). CONCLUSIONS: Institutions that participated in the collaborative had lower rates of discharge-related care failures and improved family readiness for discharge. There was no significant improvement in unplanned readmissions. More studies are needed to evaluate which interventions are most effective and to assess feasibility in non–children’s hospital settings.

Development and Implementation Results of a Venous Thromboembolism Prophylaxis Guideline in a Tertiary Care Pediatric Hospital.

OBJECTIVES Incidence of pediatric venous thromboembolism (VTE) is increasing due to increased survival of children with chronic diseases and use of interventions (eg, central venous lines), with VTE risk. Our objective was to create VTE prophylaxis guidelines with targeted identification of children at high risk to support appropriate mechanical and pharmacologic prophylaxis and integrate into the electronic medical record (EMR) as a hospital-wide quality improvement project. METHODS Patients aged 12 to 17 years were included. We evaluated institutional data regarding VTE incidence and risk factors. We evaluated literature for populations at high risk for VTE. Guidelines were formulated, and an EMR tool to assess risk and support the guidelines was created and implemented. RESULTS The EMR tool was used to screen 48% of qualified admissions for the first month and 81% in the final study month. On average, 69.1% of qualified admissions were screened monthly during the first 18 months of the program. No adverse events were reported due to pharmacologic prophylaxis. CONCLUSIONS Many risk factors are common between children and adults and certain pediatric populations warrant prophylactic consideration. Pediatric VTE prophylaxis guidelines can be successfully implemented into the EMR to identify high-risk populations. Future studies should assess the long-term impact of implementation.

Piloting Group Well Child Visits in Pediatric Resident Continuity Clinic

Introduction. Well child care is taught with individual visits in pediatric residency. Teaching residents how to deliver well child care efficiently is critical. Group well child care brings multiple families together for visits. The authors piloted group visits in pediatric residency clinic. Methods. The authors conducted group visits for 1- to 12-month old children. Seven families completed the group visits and were surveyed. Nine residents (intervention group) conducted group visits. Eighteen months after implementation, the intervention and control groups in the same clinic surveyed. Results. All families recommended group visits. The intervention group residents reported significantly more direct observations (P < .05). Trends toward improvement of teaching and role modeling for the intervention group were also observed. Discussion. The authors’ continuity clinic had success implementing group visits, and families were recommended the visits. Group visits offer a natural environment to observe residents while exposing them to another way to deliver well child care.

Family-Centered Rounding: Can It Impact the Time of Discharge and Time of Completion of Studies at an Academic Children’s Hospital?

BACKGROUND AND OBJECTIVE Family-centered rounds (FCR) involve multidisciplinary rounds at the patient bedside with an emphasis on physicians partnering with patients and families in the clinical decision-making for the patient. Although the purpose of FCR is to provide patient-centered care, an unanticipated benefit of FCR may be to improve time to discharge. The objective of this study was to determine the impact of FCR on time to discharge for pediatric patients in an academic medical center. METHODS We retrospectively compared the timing of patient discharges from July 2007 to June 2008 (before FCR) versus those from July 2008 to May 2009 (after FCR) on the pediatric hospital medicine service. We further compared time from order entry to study completion on a subset of patients receiving head MRIs and EEGs, studies that typically occurred on the day of discharge. RESULTS In our center, before FCR, 40% of patients were discharged before 3:00 pm (n = 912). After FCR, 47% of children were discharged before 3:00 pm (n = 911) (P = .0036). Time from order entry to study completion for MRIs and EEGs decreased from 2.15 hours before FCR (n = 225) to 1.73 hours after FCR (n = 206) (P = .001). CONCLUSIONS FCR provided a modest improvement in the timeliness of the discharge process at our institution.

Journal club blog for faculty paediatricians

taining small group size and the ‘take-home’ points. We plan to make a minor change for next year, based on one preceptor’s suggestion. During the final summation in stage 2, this preceptor visited each table and asked randomly selected ‘nonexpert’ students to summarise the ‘take-home’ points for each article. This may further encourage students to engage in stage 2, knowing they may be responsible for summarising the major points of the paper. Our traditional journal clubs involved up to a dozen small groups with a dozen preceptors. With this technique, using a smaller number of preceptors, we achieved a higher level of student engagement compared with traditional journal club exercises.

Multifaceted quality improvement initiative to decrease pediatric asthma readmissions

ABSTRACT Background: Asthma is the most common chronic disease of childhood and a leading cause of hospitalization in children. A primary goal of asthma control is prevention of hospitalizations. A hospital admission is the single strongest predictor of future hospital admissions for asthma. The 30-day asthma readmission rate at our institution was significantly higher than that of other hospitals in the Childrens Hospital Association. As a result, a multifaceted quality improvement project was undertaken with the goal of reducing the 30-day inpatient asthma readmission rate by 50% within two years. Methods: Analysis of our institutions readmission patterns, value stream mapping of asthma admission, discharge, and follow-up processes, literature review, and examination of comparable successful programs around the United States were all utilized to identify potential targets for intervention. Interventions were implemented in a stepwise manner, and included increasing inhaler availability after discharge, modifying asthma education strategies, and providing in-home post-discharge follow-up. The primary outcome was a running 12-month average 30-day inpatient readmission rate. Secondary outcomes included process measures for individual interventions. Results: From a peak of 7.98% in January 2013, a steady decline to 1.65% was observed by July 2014, which represented a 79.3% reduction in 30-day readmissions. Conclusion: A significant decrease in hospital readmissions for pediatric asthma is possible, through comprehensive, multidisciplinary quality improvement that spans the continuum of care.

A Step Toward High Reliability: Implementation of a Daily Safety Brief in a Children’s Hospital

Objectives Health care is a high-risk industry. To improve communication about daily events and begin the journey toward a high reliability organization, the Riley Hospital for Children at Indiana University Health implemented a daily safety brief. Methods Various departments in our children’s hospital were asked to participate in a daily safety brief, reporting daily events and unexpected outcomes within their scope of responsibility. Participants were surveyed before and after implementation of the safety brief about communication and awareness of events in the hospital. The length of the brief and percentage of departments reporting unexpected outcomes were measured. Results The analysis of the presurvey and the postsurvey showed a statistically significant improvement in the questions related to the awareness of daily events as well as communication and relationships between departments. The monthly mean length of time for the brief was 15 minutes or less. Unexpected outcomes were reported by 50% of the departments for 8 months. Conclusions A daily safety brief can be successfully implemented in a children’s hospital. Communication between departments and awareness of daily events were improved. Implementation of a daily safety brief is a step toward becoming a high reliability organization.

Before the Flood: Impact of Coordination of Care and Direct Admissions on Emergency Department Volumes

Background Transfers of pediatric patients occur to access specialty and subspecialty care, but incur risk, and consume resources. Direct admissions to medical and surgical wards may improve patient experience and mitigate resource utilization. Objective We sought to identify common elements for direct admissions, as well as the pattern of disposition for patients referred to our emergency department (ED). Design A retrospective qualitative analysis of patients transferred to our pediatric hospital for 12 months was performed. Different physician groups were evaluated for use of direct admissions or evaluation in the ED. Patients referred to the ED were additionally tracked to evaluate their eventual disposition. Results A total of 3982 transfers occurred during the 12-month analysis period. Of those, 3463 resulted in admission, accounting for 32.55% of all admissions. Transfers accepted by nonsurgical services accounted for 82% of the transfers, whereas 18% were facilitated by one of the surgical services. Direct admissions accounted for 1707 (44.8%) of all referrals and were used more often by nonsurgical services. Of patients referred to the ED (2101 or 55.2% of all referrals), most patients were admitted and 343 (16% of those referred to the ED) were discharged home. Conclusions The direct admission process helped avoid ED assessments for some patients; however, some patients referred to the ED were able to be evaluated, treated, and discharged. Consistent triage of the patients being transferred as direct admissions may improve ED throughput and potentially improve the patients experience, reduce redundant services, and expedite care.